What is the best approach to manage intermittent headaches in aseptic meningitis?

Management of Intermittent Headaches in Aseptic Meningitis

For intermittent headaches in aseptic meningitis, supportive care with acetaminophen and NSAIDs is the mainstay of treatment, focusing on symptom management rather than specific antiviral therapy for most cases. 1

Diagnostic Considerations

• Aseptic meningitis typically presents with meningism and headaches occurring in up to one-third of patients, often accompanied by fever, nausea, vomiting, photophobia, and stiff neck 1, 2
• CSF analysis is essential for diagnosis, showing:
  • Increased protein
  • Pleocytosis (increased white cell count)
  • Normal glucose
  • Negative gram stain and cultures 2, 3
• Distinguishing between viral and bacterial causes is crucial as management approaches differ significantly 1
• Laboratory investigations should include:
  • Blood cultures (prior to antibiotics if possible)
  • PCR testing for pneumococcal and meningococcal disease
  • Glucose and lactate measurements
  • Full blood count, urea, creatinine, electrolytes, liver function tests 4

Treatment Algorithm for Intermittent Headaches

First-Line Management

• Acetaminophen and NSAIDs for headache relief 1
  • Caution: Monitor for NSAID-induced aseptic meningitis, which can occur as a hypersensitivity reaction, especially in patients with underlying conditions like systemic lupus erythematosus 5, 6
• Ensure adequate hydration and rest 1
• Monitor for neurological deterioration that might suggest encephalitis rather than meningitis 1

Specific Viral Etiologies

• For enterovirus (most common cause):
  • Supportive care only, as no specific antiviral treatment has proven effective 7
• For HSV-2 meningitis:
  • Aciclovir 10 mg/kg IV every 8 hours until resolution of fever and headache
  • Follow with valaciclovir 1g three times daily to complete a 14-day course 1
• For VZV meningitis:
  • Intravenous aciclovir (10-15 mg/kg three times daily)
  • Consider short course of corticosteroids, especially if there's a vasculitic component 4

Post-LP Headache Management

• Post-LP headaches (which may complicate the clinical picture) typically have a low-pressure phenotype (worse upright, better lying flat) 4
• Management of post-LP headache:
  • Usually self-limiting and resolves without specific treatment 4
  • No evidence that bed rest, reduced CSF volume collection, increased hydration, or caffeine prevent post-LP headache 4
  • Persistent cases may require a blood patch 4

Follow-Up Care

• Many patients may feel well at discharge but cannot immediately return to normal activities 1
• Monitor for common post-meningitis symptoms:
  • Fatigue
  • Sleep disorders
  • Emotional difficulties 1
• Consider staged return to work or studies, starting part-time 1
• Early referral to mental health services may be necessary for emotional difficulties 1

Clinical Pitfalls to Avoid

• Failing to distinguish between viral meningitis and encephalitis, which requires different management 1
• Overuse of antivirals in cases where they have not shown benefit 1
• Missing altered consciousness, which suggests alternative diagnoses such as bacterial meningitis, encephalitis, or other intracranial pathology 1
• Overlooking drug-induced aseptic meningitis, particularly in patients taking NSAIDs for headache management 5, 6
• Assuming all headaches in aseptic meningitis have the same etiology - some may be post-LP headaches requiring different management 4

Special Considerations for Recurrent Meningitis

• Most cases of recurrent meningitis are caused by HSV-2 in young adults 7
• For recurrent HSV meningitis:
  • Early administration of acyclovir, valaciclovir, or famciclovir can shorten episode duration
  • Daily prophylactic administration of these medications reduces the frequency of future episodes 7